Running head: CHLORHEXIDINE USAGE

Chlorhexidine Usage in the Prevention of VAP

Chelsea DeLuca
University of South Florida

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Abstract

Ventilator-associated pneumonia (VAP) is one of the most common nosocomial

infections in mechanically ventilated patients, resulting in increased hospital stays, increased
healthcare costs, and increased patient mortality. Chlorhexidine oral swabs as a prevention
method for VAP will be examined. CINAHL and PubMed search engines were used with the key
words ventilator associated pneumonia, chlorhexidine, oral swabs, and clinical
guidelines, to find trials. The randomized, controlled clinical trials utilized in this paper showed
that chlorhexidine oral swabs are a better protective agent than oral swabs without chlorhexidine.
The rates of VAP infection were found to be significantly lower in two of the three studies. In
the third study, the rate between the control and the intervention group was not significantly
different, but chlorhexidine was protective against VAP in patients who did not have potentially
pathogenic microorganisms in their oropharynx at baseline. A nurse-directed policy change
should be made that makes chlorhexidine usage the norm in mechanically ventilated patients.

CHLORHEXIDINE USAGE

Chlorhexidine Usage in the Prevention of VAP

Ventilator associated pneumonia (VAP) is a huge problem in hospitals across the
country. It is one of the most common nosocomial infections found in mechanically ventilated
patients. Over 250,000 cases of VAP a year are reported in United States hospitals with about
36,000 resulting in death (Center for Disease Control and Prevention, 2014). VAP is frequently
found at Bayfront Medical Center and the administration and staff have expressed an interest in
changing their practices to try to improve this statistic. This paper will address the question: In
adult, critically-ill patients that are mechanically ventilated, how does the use of oral
chlorhexidine compare to standard oral care (no chlorhexidine use), in reducing the prevalence of
VAP over a 6 month period? In order to implement a change associated with chlorhexidine
usage, hospital administration would have to approve of such a change. The first step would be
to talk to hospital administration about the costs and benefits of this change. Once the change
was approved, it would need to be piloted in one or two units before spreading to the rest of the
hospital, in order to address any issues that might come up on a smaller level.
Literature Search
PubMed and CINAHL search engines were used in order to find appropriate studies to
include. Specific keywords used in the search included ventilator associated pneumonia,
chlorhexidine, oral swabs, and clinical guidelines. Three randomized, controlled clinical trials
and one clinical guideline were used, that focused on the prevention of VAP and chlorhexidine
usage.
Literature Review
Grap et al. (2011) conducted a randomized controlled trial to examine if chlorhexidine
administration to the mouth and oropharynx would reduce the incidence of ventilator-associated

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pneumonia. The intervention group received a 5 mL application of 0.12% chlorhexidine by

swab, while the control group received no swab. The intervention was tested 12 hours after
intubation. A total of 145 trauma patients were included in the study. There were 71 patients
placed in the intervention group and 74 patients placed in the control group.
The patients were evaluated for VAP on admission, at 48 hours after intubation, and at 72
hours after intubation, using a Clinical Pulmonary Infection Score (CPIS) scale. Results showed
that 55.6% of patients in the control group developed VAP, while only 33.3% of patients in the
intervention group did. These results were found to be significant with p=0.020.
Some strengths of the trial included randomization, and the control and intervention
groups were similar in demographics. One weakness of the study was the CPIS (Clinical
Pulmonary Infection Scale) was used to determine the development of VAP. Since the
completion of the study, other studies have found that this may not be the most appropriate way
to determine the development of VAP (Grap et al,, 2011).
Kusahara, Peterlini, and Pedreira (2012) conducted a randomized-controlled clinical trial
to determine if the incidence of VAP was lower in mechanically ventilated critically ill patients
when oral care with 0.12% chlorhexidine was used. Both the medical professionals and the
participants were blinded to group assignments. There were a total of 96 participants from a
pediatric critical care unit. Fifty children were assigned to the control group and 46 were
assigned to the intervention (chlorhexidine) group. Both the intervention group and the control
group received twice daily oral care, including tooth brushing. The intervention group had a
specific dental gel that contained chlorhexidine, while the control groups did not contain
chlorhexidine.

CHLORHEXIDINE USAGE

The primary outcome used to measure the effectiveness of the intervention was the
development of VAP during their time in pediatric intensive care. Secondary outcomes were
used as well, including length of ventilation, length of stay in the pediatric intensive care unit,
hospital mortality, and oral and tracheal colonization with either gram negative or gram positive
microorganisms. Microbiological cultures were performed on oropharyngeal and tracheal
secretions at 24, 48, and 96 hour intervals after intubation. Results showed that 32.6% of patients
in the intervention group developed VAP, while only 32.0% of patients in the control group
developed VAP. The use of chlorhexidine was not found to be significantly effective in this
study overall, but it was found to be protective against VAP in children who did not have
potentially pathogenic micro flora in their oropharynx at the 24 hour culture. There were fewer
children in the chlorhexidine group that developed VAP, when no micro flora was present at 24
hours, than there were in the placebo group (p=0.019).
This trial had many strengths, including randomization, and similarity of both groups in
demographics. Additionally, it was double-blind and had clear statement of the primary and
secondary outcomes. Although this study takes place in a pediatric population and does not show
significant results overall, it is still appropriate for inclusion in this project because it shows the
comparison between oral swabs without chlorhexidine, and those with chlorhexidine. It also
shows significant results in children who had no pathogenic micro flora present at the 24 hour
swab (Kusahara et al., 2012).
zaka et al. (2012) performed a randomized, double-blind clinical trial to evaluate the
effectiveness of using 0.2% chlorhexidine gluconate solution in decreasing risk of ventilator
acquired pneumonia. Sixty-one patients were involved in the study, split into a control group and
an intervention group. Twenty-nine patients were assigned to the intervention group and thirty-

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two patients were assigned to the control group. Both groups received swabbing of the oral
cavity four times daily for one minute; the control group with saline solution and the intervention
group with chlorhexidine solution. Periodontal measurements were obtained on admission as
well as lower-respiratory tract specimens. VAP rates in the control group were 68.8% and 41.4%
in the intervention group, which was significant (p=0.03). No differences of significance were
reported in the periodontal measurements.
Strengths of the study included randomization of participants, and blinding of
participants, as well as healthcare coordinators. Also, the control group and the intervention
group were similar in demographic make-up. Additionally, the researchers provided explanation
from the participants who failed to complete the study (zaka et al., 2012).
Kollefs (2014) clinical guideline for the prevention of VAP suggests that chlorhexidine
oral swabs be used, and suctioning be done as needed. Both of these are evidence-based
interventions that are proved to prevent the development of VAP.
See Table 1 for further information on each study.
Synthesis
Together, these studies prove that the use of chlorhexidine oral swabs is more effective at
preventing the development of VAP, than oral swabs not containing chlorhexidine. Although the
research proves that chlorhexidine is a better alternative, there are still a good amount of patients
who contract VAP, and this issue still needs to be addressed further.
The most effective prevention for VAP in the research, is an initial application of
chlorhexidine within 12 hours of intubation. This is shown to reduce VAP rates with the highest
proportion. There are still some gaps in the research though, because VAP still occurs in a large
number of patients, even with chlorhexidine usage. Further research could look at what other

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procedures could be added to the chlorhexidine regimen, to further decrease the frequency of
VAP. Also, these studies have not done long term follow up, to ensure that the chlorhexidine has
no long term effects on patients.
Proposed Practice Change
In order for the hospital to make its practice evidenced based, they need to implement an
oral care regimen that involves chlorhexidine for all mechanically ventilated patients. Nurses
should perform an initial application of 5 mL of 0.12% chlorhexidine, within twelve hours of
intubation. Then, nurses should administer 5 mL of 0.12% chlorhexidine to patients twice daily,
for the remainder of the time that they are mechanically ventilated. Each oral swab procedure
should last at least one minute.
Change Strategy
It is important to get the staff members involved in the change process, in order to help
them understand why the change is being put into place, and to get their support on the change.
One important way to engage the staff is to present the evidence to support the intervention.
Having a meeting with staff members where a presentation about the effectiveness of
chlorhexidine in preventing VAP is addressed, could greatly improve the staffs desire to
implement the intervention, and increase their support for the change. Additionally, it is crucial
to have educational sessions where the nurses and other staff are taught the appropriate technique
for using the oral swabs. This will ensure consistency across all patients, and will help with
evaluation of the intervention.
The Stetler Model of Evidence-Based Practice will be used to implement this practice
change at the facility. The model was chosen because it is the model used at the facility where
this new intervention will be implemented (Melnyk & Fineout-Overholt, 2011).

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Roll Out Plan

Step 1: Preparation

Select resources appropriate for the project.

This problem is a priority for the institution because of the high rates of VAP
present in the institution. It is a priority for all hospitals because VAP is a
hospital-acquired infection that does not receive reimbursement from many
insurance companies. It is also a priority issue because it can result in loss of life
or lengthened hospital stays.

Purpose/expected outcome: reduction of the incidence of VAP in mechanically

ventilated, adult, critically-ill patients.

Quality improvement data suggests that VAP is a large issue in the hospital.
Additionally, the issue does not seem to be improving with the interventions in
place right now.

Time frame: June 2014

Step 2: Validation

The evidence supporting the use of chlorhexidine is strong. All three randomized
controlled clinical trials suggest that there is a significant difference in patient
outcomes with the use of chlorhexidine.

All non-credible sources have been eliminated from the evidence base.

Time frame: July 2014

Step 3: Comparative evaluation/decision-making

Findings were synthesized above.

CHLORHEXIDINE USAGE

There are no real risks associated with chlorhexidine usage. Allergic reactions are
a risk, but they are a risk with any sort of intervention.

The hospital staff seems ready for a change with mechanically ventilated patients.
They have expressed interest in finding an intervention to further help prevent
VAP and other negative outcomes for mechanically ventilated patients.

This intervention should be used as soon as possible to prevent as much VAP as

possible.

Time frame: July 2014

Step 4: Translation/application

The evidence will be used directly. It will be used to educate the staff about how
effective using chlorhexidine is, as well as methods of how chlorhexidine should
be used.

Formal dissemination will be a gradual process. The process will start with one
unit, the coronary care unit, where the vast majority of ventilated patients are.
After the pilot unit has successfully implemented the use of chlorhexidine, it will
be disseminated to the rest of the hospital using teaching seminars. Finally, after it
is proven to be effective at the pilot hospital, it will be disseminated to other
hospitals, also through teaching seminars.

Time frame:
o Pilot unit: beginning December 2014 and lasting for 6 months (unless
issues arise that need to prolong the pilot process).
o Pilot hospital: begin moving to all units in June 2015; pilot hospital will be
in effect for one year before dissemination to other units.

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o Other hospitals: beginning June 2016.

Step 5: Evaluation

The use of chlorhexidine will be continuously evaluated throughout the

implementation process. It will be evaluated using rates of VAP, and throat swabs
for microorganisms.
Project Evaluation

This intervention will be evaluated by the primary outcome of reduction of VAP rates.
These rates will be obtained from patient records. The rates will be compared to rates from
previous years and the effectiveness of the chlorhexidine will be evaluated. Specific parameters
that will indicate success are VAP rates being lowered by 20% in the first year of
implementation.
A secondary measure that should be used to evaluate the effectiveness of the
chlorhexidine intervention is throat swabs. Swabs should be taken at baseline to determine if
there is pathogenic microflora present. Additionally, swabs should be taken once a patient is
found to have VAP, to find the causative agent. These two swabs should be correlated to see if
the causative agent was present in the baseline swab as well.
Dissemination of EBP
The dissemination process would be a gradual one. The first step would be a pilot unit.
The pilot unit would be the coronary care unit (CCU) where the majority of mechanically
ventilated patients are. This unit would receive education on the effectiveness of chlorhexidine in
the prevention of VAP, and on the appropriate process for using the chlorhexidine oral swabs.
This unit would continue the intervention for six months before it was disseminated to the rest of
the hospital. If any issues came up, they could be dealt with on this small scale, and the length of

CHLORHEXIDINE USAGE
the pilot could be adjusted accordingly. The effectiveness of the intervention would also be
evaluated on this small scale.
At the end of the six months, the intervention would be disseminated to the rest of the
hospital. All staff would receive educational seminars like the ones on CCU. The effectiveness
would continue to be monitored. This would take place for one year before dissemination to
other hospitals. Dissemination to other hospitals would take place using the same educational
seminars, and any further educational seminars that each hospital feels necessary.

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Table 1
Literature Review
Reference
Grap, M., Munro, C. L.,
Hamilton, V., Elswick, R. K.,
Sessler, C. N., & Ward, K. R.
(2011). Early, single
chlorhexidine application
reduces ventilator-associated
pneumonia in trauma patients.
Heart & Lung, 40(5), e115-22.
doi:10.1016/j.hrtlng.2011.01.006

Kusahara, D., Peterlini, M., &

Pedreira, M. (2012). Oral care
with 0.12% chlorhexidine for the
prevention of ventilatorassociated pneumonia in
critically ill children:
Randomised, controlled and
double blind trial. International
Journal Of Nursing Studies,
49(11), 1354-1363.
doi:10.1016/j.ijnurstu.2012.06.00
5

Aims

Design and
Measures
To
Active studydetermine if patients were
the usage of enrolled once
chlorhexidin they entered
e oral swabs the hospital.
decreased
CPIS (Clinical
the risk of
pulmonary
VAP in adult infection
trauma
scale) was
patients.
used to
evaluate if
VAP was
present or not.

To
determine if
the usage of
0.12%
chlorhexidin
e oral swabs
reduced the
rate of VAP
in children
on a
pediatric
critical care
unit.

Sample

Outcomes /
statistics
A total of
A significant
145 patients difference
were
between
enrolled-71
CPIS score
patients in
at admission
the
and at 48
intervention (p=0.020)
group and 74 and 72
in the
(p=0.027)
control
hours after
group.
intubation
Eighty-five
were found
of these
to be
patients were significant,
not included indicating
in the final
that the
evaluation
intervention
because they group had a
were
lower
intubated for incidence of
less than 48
VAP.
hours or
information
for the CPIS
score was
not
adequate.
Active study- The
No
patients were
chlorhexidin significant
recruited on
e group
difference
admission to
consisted of was found
the hospital.
46 children
between the
The primary
and the
two groups
outcome
control
in the
variable was
group
development
VAP
consisted of of VAP.
development
50 children. However, in
during
children who
hospitalization
did not have
.
potentially

CHLORHEXIDINE USAGE

zaka, . ., Baolu, . K.,

Buduneli, N. N., Tabakan, M.
S., Bacakolu, F. F., & Kinane,
D. F. (2012). Chlorhexidine
decreases the risk of ventilatorassociated pneumonia in
intensive care unit patients: a
randomized clinical trial. Journal
Of Periodontal Research, 47(5),
584-592. doi:10.1111/j.16000765.2012.01470.x

13

To
determine if
using 0.2%
chlorhexidin
e gluconate
solution
decreases the
risk of
ventilator
acquired
pneumonia
in adult
intensive
care patients.

Active studypatients were

enrolled in the
study upon
admission to
the hospital.
Primary
measures for
the study
included
development
of VAP during
hospital stay
and any
changes in the
dental exam.

pathogenic
microflora
present in
their
oropharynx
at baseline,
chlorhexidin
e was found
to be
protective
against
VAP.
(p=0.019)
Sixty-six
The rate of
patients were VAP
included in
development
the study: 34 was
in the
significantly
control
higher in
group and 32 patients in
in the
the control
intervention group
group.
(p=0.03).

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References

Center for Disease Control and Prevention. (2014). VAP. Retrieved June 30, 2014, from CDC:
http://www.cdc.gov/nhsn/pdfs/pscmanual/6pscvapcurrent.pdf
Grap, M., Munro, C. L., Hamilton, V., Elswick, R. K., Sessler, C. N., & Ward, K. R. (2011).
Early, single chlorhexidine application reduces ventilator-associated pneumonia in
trauma patients. Heart & Lung, 40(5), e115-22. doi:10.1016/j.hrtlng.2011.01.006
Kollef, M. (2014). Prevention of hospital-associated and ventilator-associated pneumonia.
Critical Care Medicine, 32(6), 1396-1405.
Kusahara, D., Peterlini, M., & Pedreira, M. (2012). Oral care with 0.12% chlorhexidine for the
prevention of ventilator-associated pneumonia in critically ill children: Randomised,
controlled and double blind trial. International Journal Of Nursing Studies, 49(11), 13541363. doi:10.1016/j.ijnurstu.2012.06.005
Melnyk, B. & Fineout-Overholt, E. (2011). Evidence Based Practice in Nursing and Healthcare.
Lippincott Williams & Wilkins.
zaka, . ., Baolu, . K., Buduneli, N. N., Tabakan, M. S., Bacakolu, F. F., & Kinane,
D. F. (2012). Chlorhexidine decreases the risk of ventilator-associated pneumonia in
intensive care unit patients: a randomized clinical trial. Journal Of Periodontal Research,
47(5), 584-592. doi:10.1111/j.1600-0765.2012.01470.x